Midwifery Ethics February 8, 2010

Midwifery deserves its own model of ethics.  Midwives have usually adopted ethics from other fields, such as medicine.  Yet, midwives’ relationships with clients are unlike those between doctors and patients.  For one, midwives embrace a model of care that is woman-and-family-centered.  Also, midwives typically develop intimate relationships with the mothers we serve and see ourselves as their partners in care. Medical ethics, which are typically abstract and devoid of relationships, are not the best fit for midwifery practice.  Midwifery needs a model of ethics that reflects the Midwives Model of Care.

The main principles of bioethics are applicable to midwifery.  Beneficence, to benefit others; and nonmaleficence, do no harm, are relevant to all helping-professions.  Yet, to practice these, along with justice, diversity, dignity and autonomy, midwives’ use an ethics of caring.

Caring is a feminine value, and it is how women often approach ethics.  While landmark research in moral development demonstrates that boys use the concept of justice to make moral decisions, Carol Gilligan found that girls do so by use of caring.  It makes sense that midwives would approach ethics similarly.   In fact, through an ethics of care, midwives maintain a client’s dignity in ways that contrast dramatically with the field of medicine.

To apply bioethical principles, midwives consider their relationships with others.  For example, when a midwife is faced with an ethical dilemma, she considers not only principles of bioethics, but also the effects that ethical decisions have on her client, the client’s family, the midwife’s practice, and her co-workers, workplace and community.  The same kind of relational and caring ethics should be applied when working with others, or non-clients, such as other midwives, physicians, apprentices, supervisors, and complementary and alternative care providers.

In considering ethics for midwives, it is important to recognize the caring and relational aspects of the Midwives Model of Care that affect how midwives make ethical decisions.  The Midwives Ecological Model of Ethical Thinking (MEMET) illustrates midwives’ unique approach to ethics.  With the midwife and client relationship at it’s center, and the support network, practice setting, and other historical and cultural considerations, the MEMET demonstrates the complex and relational influences on midwives’ ethical thinking.  This model is introduced in Professional Ethics in Midwifery Practice (Jones & Bartlett, 2010).

Making healthy food choices in pregnancy October 7, 2009

Building a healthy baby and maintaining a healthy mama requires attention to nutrition.  Processed foods do little to support our bodies, providing only empty calories and preservatives.  Making healthy food choices in pregnancy can lead to improved nutrition for your family throughout the lifespan.  The journey of healthy eating usually begins with education-learning about the importance of minerals and vitamins, the accessibility of nutrients in specific foods, and healthy cooking. The next step takes place at the grocery store.

Choosing fresh produce that is seasonal and local, whenever possible, will increase the nutritional value in your food. Be aware of the temptation to overload the cart with too many good choices, which can often rot in the fridge if you don’t eat them quickly.  Smaller and more frequent purchases can ensure that your food is fresh when you prepare a meal.  Most big cities around the globe have farmers markets and fruit and vegetable stands along major routes, but in the U.S., we often have to drive to a supermarket to find our produce.  This inconvenience can be a barrier to getting fresh fruits and vegetables regularly, but this can be overcome by growing your own food, even just one or two plants, and locating a farmers market nearby.  Autumn is a bountiful season in most locales, so it is a good time to visit a farmer and learn about seasonal foods.

Pregnant women must be sure to eat foods containing plenty of  protein, calcium and iron.  All of these nutrients are available through plants.  Soybeans are a complete protein and dried apricots contain high amounts of iron.  Calcium can be found in leafy greens and legumes.  Vegan mothers must find a supplemental source of B vitamins, especially B12.  Vegetarian mothers can add farm eggs to their menu three days a week to boost protein and omegas.  Yogurt is another whole protein source.  Choosing grass fed beef and antibiotic and hormone free chicken are safe alternatives to eating meat from concentrated feed lots, where the meat may be tainted, high in genetically modified corn products, and full of chemicals.

Making nutritional changes in pregnancy can benefit your entire family for life.

Self-care August 15, 2009

As we’re gearing up for a busy school year ahead, it is important for moms to take time for themselves, too.  To some moms, just getting time alone for a shower once a day is a welcome escape from taking care of others.  This is often the case when raising infants and toddlers.  Although the kids’ needs usually come first, there is wisdom in caring for yourself.  Loving yourself and nurturing yourself are good habits for life.  They model healthy psychosocial development for our children, as well. This doesn’t mean that I advocate putting the kids needs after yours on a regular basis.  That is for each family to decide based on their personal values and beliefs about child-rearing.  Rather, I’m advocating that as a mother, self-care is essential because mothering takes a lot of creative energy, and you can’t continue to tap that resource unless you take time to refill the source.

Take a daily walk, if you can.  That is a good beginning.  Don’t take your cell phone with you unless you need it for emergencies.  This is quiet time for your brain and body to exhale.  Extend the walk a little bit each day until you feel that you’ve reached the right amount of time and distance for your mind/body.

Write down your thoughts each day-in whatever form you wish.  This simple practice allows you to purge your thoughts and ideas, and think with more clarity.  You may have some welcomed creative outbursts, as well.  A daily journal entry of 1 page is a good place to start.

Give yourself something beautiful.  You will decide what it is.  For some moms, a massage is the perfect gift.  For others, a new skein of yarn or a cup of tea in the garden will suffice.  Some times require different measures than others.  After a particularly difficult day, perhaps mom needs time to cuddle up with a good book and some dark chocolate.

Pay attention to your own needs.  Whatever the need may be, notice it.  Try not to judge, change, or dismiss it.  Allow it to show itself.  Try to give it a name, such as “rest” or “a night out” or “a distraction.” Think about how you can address that need, including a time that it will be addressed.  Try to meet your needs where they are-based on your own resources.  A trip to Hawaii may be within the reach of some in the immediate future, but most of us need to save and plan for such an extravagance.  A dip in the local swim hole with a girlfriend may satisfy the need for natural beauty and nature in the near future.

Self-care is an ongoing process, a skill like any other work we value.  Taking the time for self-care may be difficult if you allow yourself to feel unworthy or try to play the part of the martyr who needs little and serves all.  As tempting as this role can be, it is not advisable.  Martyrdom is not a behavior we want to see manifesting with our own children, so we should do away with it in our own lives.  Self-care is an ingredient for a happy life and happy family.

Giving and receiving December 5, 2008

This time of year we feel especially drawn to give.  Giving to others is a way of deepening our community connections, offering our services to those in need without expectation, and allowing our potential for altruism to be expressed.  “Giving is more important than receiving” is a quote that I recall learning as a small child.  I’ve tried to model and teach this to my own children, but I also love getting gifts-especially symbols of appreciation.  Why do we need to express and receive appreciation, symbolically, or not?  Usually doing a job well is its own reward.  Parenting comes to mind.  You give your kids your time, energy, love.  You watch them grow and blossom.  It is enough.  Then, when a little one comes in bearing a handmade card with sincere messages and images of appreciation – the tears begin to fall.  There is such joy in giving and receiving.  It doesn’t have to be materialistic-despite what the economists say we should do.  Buying isn’t necessarily the best way to give.  It is a legitimate venue for showing appreciation, but it isn’t the only option this holiday.  Giving can be a  creative endeavor-or a simple intuitive act of kindness.  Receiving can also be an art-to open oneself to the love that is embodied in a gift-it makes your heart grow.  It is okay to receive the affection, admiration, and appreciation of others – and to love yourself a bit more in the process.

Nurturing the Nurturer November 1, 2008

Taking care of babies or women with babies, for that matter, is an enviable job.  Motherhood is the most rewarding position, work and status.  Midwifery is much like motherhood, in that we watch women becoming mothers, nurturing their mothering instincts.  When the caretaker gives (and gives) selflessly, she requires a centered foundation that is, itself, cared-for.  As mothers and midwives, we must take time to nurture ourselves.

I remember hearing this from older (i.e. wiser) friends when my children were small, and although I knew there was truth in the sage words, I also had a defensive reaction-like the mother in me was being insulted, challenged, and questioned.  I felt that my first obligation was to my kiddos-making sure their needs were met, while mine could wait.  I didn’t feel that it was a “martyr thing”, either.  Rather, it was my calling to function daily at a high-level for my kids, regardless sleep deprivation, a sore back, or PMS.   It wasn’t until my kids were seeking more independence and peer interaction that I started taking time to nurture myself.  I joined an Artist From Within group and scheduled the occasional massage and practiced yoga or danced.

Now as a mother of adolescents, I’ve committed much of my nurturing to my clients, the women and babies that I serve daily.  Their needs are my priority and I extend myself to meet them.  Now self-care is also my priority, and it feels like I rise to a higher-level of functioning each time I take time for a  yoga class or walk around the lake.  “Refilling my well” through self-nurturing:  making my favorite dish for dinner, allowing myself to sleep in, reading for pleasure…these things, like little gifts to myself, give me momentum, clarity, joy and a healthy mental outlook.  I have a good attitude and no guilt!

So, nurturing the nurturer isn’t a narcissistic endeavor-an egotisitcal excuse to indulge self at the cost of others.  No.  Women can be their best at mothering and in partnership, in part by taking care of themselves.

Opening to Baby October 26, 2008

I’ve attended a lovely stream of beautiful births in my practice over the fall.  It has been so inspirational watching 1st, 2nd, 3rd, 4th, and 5th time mothers opening to birthing and baby.  Fathers are equally amazing to watch.  Many of my clients have had 1st time homebirths-a huge shift from their previous experiences in a clinical setting.  As Mamma begins to open fully, all hearts surround and support her.  She sways and moans to the rhythm of her baby descending into the world and we wait with baited breath.  Soon, Mamma’s body will guide baby as the little one dances through the birth canal into newness.  When the baby’s head is first visible, joyful excitement swirl-time seems to stop.  The little one emerges, face pressed tightly closed at first.  As Mamma or Pappa reaches down to take baby, a huge opening-one that is nearly audible-emerges.  Fathers weep, laugh, and sigh, and coo.  Eyes light upon the new loved one.  A hush sweeps through the room and baby opens up to belonging.  Aha!  I am here!  I’ve always been here!  YOU~

gentle caring July 30, 2008

The central role of a midwife is gentle caring. A woman and her family present their challenges to you at various stages of the childbirth year. Midwives must always be open and take time to listen. This is perhaps the most important quality of gentle caring. When a woman feels safe in opening up, she learns from herself. We are there to witness her growth. We don’t have control over her journey, nor can we navigate it for her. It is hers alone. Being there for women in times of need is an honor. Recognizing the central importance of listening and showing sincere compassion is the midwife’s job. It can be challenging to be truly present all the time, but it is a quest we must all challenge ourselves to meet if we are drawn

Breastfeeding challenges June 7, 2008

In the past year I’ve had a few clients with breastfeeding challenges. Specifically, these involve a baby who has difficulty with latch or sucking. The best resources that I’ve found are La Leche League’s The Breastfeeding Answer Book and the experienced lactation consultant. As a midwife, I provide full breastfeeding support to my clients, and it is well documented that clients of midwives have a significantly higher rate of breastfeeding success than women attended by physicians birthing in hospitals. I provide breastfeeding education prenatally, as well as access to my library of breastfeeding books. Although every situation is different, it is preferable for the baby to latch on with the mother’s gentle guidance soon after the birth. I often assist with first-time mothers with this process. When I visit on the 1st, 3rd and 5th day after the birth, breastfeeding support is often the primary focus of my work.

Yet, when a young baby is born early or when a baby has a structural barrier to effective breastfeeding, I turn to my resources. The nipple shield and a product known as “The Breast Friend.” have been effective tools in overcoming initial latch and suck problems, in addition to some brief training on the gloved-pinkie-finger. Latching is easier on Mom when she hand-expresses a bit of milk to soften nipple and to motivate the baby to “nipple” the drops that are excreted. Patience is a key component to successfully overcoming these challenges. Babies need time to learn, and so do mommies.

Midwives who watch, wait and encourage, offering appropriate suggestions in a manner that is non-intrusive and non-critical, can be a great comfort and source of information and support to new mothers and babies. Another resource that I’ve been utilizing in my practice is peer mentoring. Moms who have overcome similar challenges are the best teachers for new mothers who are frustrated, yet determined to establish successful breastfeeding. Sometimes I turn to those with the extra training and experience with breastfeeding challenges, the lactations consultants and La Leche League. A talented lactation consultant can bring a higher level of knowledge and additional tools on board to assist the family. Often, just one meeting with a consultant is all it takes for the mother to implement the suggestions and master techniques. La Leche League can offer a supportive community to the family and invaluable literature to both practitioners and new mothers.

Breastfeeding is a central component to healthy infant development. Assuring that my clients have every resource that they need to achieve successful breastfeeding is critical to my midwifery care. Sometimes, this entails bringing in another professional.

Choosing a midwife April 30, 2008

When a woman calls me who is expecting a baby or planning a pregnancy, I often ask her why she is interested in hiring a midwife. I’m so curious about what brings women to make this choice, so contrary to mainstream conditioning about fear around birth and the necessity of technological and medical assistance to birth. Many women tell me that they want a natural birth or a minimum of interventions in their birthing process. Sometimes I hear that a woman wants the support of a midwife (from mid-wife or with-woman). Other women want to avoid hospitals and the attendance of a male physician at the birth. There are numerous reasons why women choose midwives, but these are common themes for mothers who are having their first baby or their first out-of-hospital birth.

Although all of these reasons are valid, I often feel motivated to share more with the woman about the midwifery model of care-holistic, intimate, woman-centered, etc. It takes a while for this concept to sink in-that birth has been co-opted by the medical field-and that another completely different paradigm exists. It is so exciting to me that I want all women to understand that hiring a midwife is a lot more that a natural birth experience. It is an opportunity to grow into motherhood in a completely supportive environment-every step of the way-from conception through breastfeeding and beyond. Not that there isn’t a place for obstetrics-there clearly is a need for this specialty. But women deserve the right to know about their choices.

As long as they are having a healthy pregnancy, women can choose to have a midwife care for them during pregnancy, birth and the postpartum/newborn period. It is cheaper, more natural, more woman-centered, more empowering, and more supportive than they can find in the medical world. I hope more women have the opportunity to learn about their choice to choose a midwife!

A hospital “Natural birth” April 18, 2008

When I was pregnant with my first child more than sixteen years ago, I was clueless about midwifery and homebirth options. I lived in a suburb of Corpus Christi, TX that was populated with tiny tots and new moms, as evidenced by the sidewalk-sprinkling of strollers and tricycles. I read the standard books of the time, including What to Expect When You’re Expecting and Dr. Spock’s Baby and Child Care. I found a friendly OB/GYN who was a D.O., rather than an M.D. I thought her osteopathic training would translate to a holistic approach. It was 1992, and my town boasted a single health food store, so I had limited access to information about healthy living and natural childbirth. I had, fortunately, attended the local state university and studied child development. So I had an idea of what my expectant child was going to need from me when she arrived, I thought.

During my pregnancy, I heard about a local midwife from a friend. Curious, I made an appointment to meet with her to discuss natural birthing. She was friendly and generously lent me a stack of books and offered to attend my planned hospital birth. I didn’t seek her services, thinking that I had things under control, but I did read her books. They led me to create a birth plan which I brought to my doctor’s office at visits, along with written questions about episiotomies, epidurals, rooming-in with my newborn, etc. My doctor seemed fairly receptive to my ideas and questions.

I became slightly annoyed at the standard long wait in my doctor’s office: honestly, the average wait was 45 minutes-an hour before I was invited in to pee in a cup for and be weighed by a nameless assistant. Then, I’d wait again for the doc. When she’d arrive, I was all gushy and inspired…wanting to fill the 5-10 minutes in her presence with as much meaningful information sharing and bonding as possible. She was polite, but didn’t connect with me in a way that felt meaningful to me. I had my check-up and left to wait in the payments line.

Finally, when I went into labor, my doctor took my call. She “let” us come in to the hospital for a labor check, but I found that my labor slowed when they set me into the wheelchair and whisked me off to my room. I was disappointed when she sent me home, stating that I wouldn’t be in real labor for another couple of days.

Since they hadn’t allowed me to eat a single bite, I went directly to the local cafe for a sandwich, feeling ignorant and discouraged. Then, I puked up the club and pickle, and my contractions came back! I didn’t want to call my doc, though. I went home and sat out for another hour or two as contractions bellowed in my pelvis. I didn’t have the tools or knowledge then to know to trust my body. I had never heard of such a concept! I became scared and wanted to go to the hospital, so we called the doc again who, clearly annoyed, asked me to stay on the line through a contraction or two. When I was unable to talk, she consented that we could return to the hospital.

In the car, I found the contractions to be unbearable, but upon arriving at the hospital and checking in, they slowed again! I was in disbelief! What was going on? They allowed me to stay this time, strapping all of the required machines to me and placing the standard IV in my arm. I was content. This was really happening, or they wouldn’t let me stay-right? So, when my doc came back and checked me, I was devastated with her claim that I wouldn’t have my baby until tomorrow or the next day! ARRGH! With a “humph!”, she left for the day.

It was then that I surrendered, and my labor came on strong. I was limited in my ability to move, but I tried the hands-knees position that I’d read about in the midwife’s books. I wagged my tail with back-labor. The L&D nurses pleaded with me to get the epidural and be quiet so that other moms wouldn’t be frightened by my groans. I was both embarrassed and outraged! I was in labor, too-and without drugs! I denied each of their attempts to push drugs on board my healthy young body. I had to argue with them to go to the toilet (because they had to unhook my fetal monitor and follow me with the IV), and I noticed that my strongest contractions came to me alone in the bathroom. In between contractions, the nurses limited my intake to a few ice chips, but I was so thirsty! Why couldn’t I have more? It seemed cruel that my mouth was so dry as I worked hard to birth my first baby.

When I vomited in transition (reaching 7cm in dilation), the nurse insisted that I take something, as it was my last chance. With a nod from my mother, who hated to see me working, I gave in. But it was too late for the epidural, so they gave me Demerol intravenously. I became sleepy between contractions, although I got up into my working labor pattern as they came on. They barely took the edge off the contractions, but I did rest in short bouts between. I wasn’t aware at the time that I was endangering my baby with a narcotic.

Finally I was ready to push, but the doctor, whom I hadn’t seen since my “welcome” back to the hospital, was doubtful. When her eyes lit up at my complete cervix and descending head, she said she’d have to cut an episiotomy. Both my spouse and I protested, but she insisted, and cut before my baby crowned. My beautiful baby was born healthy and I held her and protectively guarded her, getting her onto the breast myself with encouragement from my mother. After 45 minutes of my refusals to separate from her, they took her from me.

I went to the shower and cried hard for her return. Then, when I got her back, I insisted on her rooming-in. They were, of course, reluctant. I had to have a second person in the room so that I wouldn’t fall asleep and drop the baby on the floor. It was clear that I had to get out of there a.s.a.p.! But my bottom was soooo sore. The episiotomy had caused me a great deal of pain and the doctor denied that my pain was real. She was angry that I complained about it and refused the pain relief I didn’t ask for. I went home the morning after my baby’s birth so that I could be left alone to nurse, sleep, and bond with my baby. They sent me home with formula, bottles, and coupons for more.

I didn’t find out until 6 weeks later, after many painful weeks of toileting and sitting on pillows, that the wound left a hole in my perineum that would take years to heal properly. My doc hadn’t even shown up to this one postpartum visit-her male partner was there, and I felt abandoned and violated.

Still, I had a vaginal delivery, largely free of drugs, and I was able to successfully breastfeed (a battle I won with the hospital nursery). My daughter is happy and healthy, and I had learned a lot! I learned that natural birth is extremely rare at the hospital, and it usually involves a mom who is progressing so quickly that there is no time to intervene. I learned that midwives are the experts of natural birth, so I sought one for my second pregnancy. I learned that I had to advocate for what I want for my family without ever backing down. I learned to be a conscious consumer of medical care, limiting it to necessities only, not natural life events, such as normal birth.